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Clozapine Cardiac Guidelines

  Department for Health and Wellbeing, Government of South Australia.  All rights reserved.  FIS: 20079.6. March 2022

Ba
se

lin
e

Prior to 
Clozapine 

therapy

Troponin T or I High sensitivity test preferred Not all pre-existing 
cardiac abnormalities 
preclude clozapine 
treatment. Consult 
a cardiologist if 
abnormalities are 
detected

hs-CRP High sensitivity c-reactive protein test

Echocardiography Highly desirable, Mandatory for community starts
ECG

Du
rin

g 
Cl

oz
ap

in
e 

Th
er

ap
y

First  
28 days

At all times Educate participants and carers to report flu-like symptoms,  GI upsets, dizziness or chest pain

Once a day Measure body temperature at the same time each day

During 
Initiation 
(First 18 
weeks)

Days 7, 14, 21 and 28, 
week 12 then  
annual review

Troponin T or I, hs-CRP, ECG (except day 21) Pulse, Blood Pressure, 
Respiratory Rate

If at any time

Temperature &gt;38 C
or

flu-like symptoms
Immediate hs-CRP, troponin  
and CBE.

Continue clozapine at 
current dose. Do not 
escalate until features 
normalise

Troponin &gt;60ng/L and 
hs-CRP elevated

Urgent transfer to Emergency 
department. Urgent cardiology 
consultation   query myocarditis.

Urgent echocardiography.

Withhold Clozapine

Troponin &gt;60ng/L  
and normal hs-CRP

Urgent transfer to Emergency 
Department. Urgent cardiology 
consultation   query acute coronary 
syndrome (ACS).

Continue clozapine at 
current dose. Do not 
escalate until features 
normalise

Troponin 30-60ng/L  
and elevated hs-CRP

Daily assess troponin, hs-CRP and 
symptoms until features normalise. 
If no progressive elevation, consider 
differential diagnosis and cardiology 
consultation.

Continue clozapine at 
current dose. Do not 
escalate until features 
normalise

Annually

Troponin T or I High sensitivity test preferred

hs-CRP High sensitivity c-reactive protein test

Echocardiography

ECG

Adapted with consent from Clozaril Protocol CPMS- V5 30 Sept 2019

NB: with the change to a more sensitive troponin T assay range (13ng/L for females and 17ng/L for males) consideration  
as to whether cases of myocarditis would be missed has been given. SA Pathology still consider that a troponin T &gt;30ng/L 
is appropriate for an action point for a value 1-2 times the upper level of normal and troponin T &gt;60ng/L is appropriate for 
an action point for a value 2 times the upper level of normal.


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